Provider Demographics
NPI:1023826559
Name:BERGEMANN, MICHAEL (LPC-IT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERGEMANN
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5214 CAMILLA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2437
Mailing Address - Country:US
Mailing Address - Phone:815-821-3596
Mailing Address - Fax:
Practice Address - Street 1:521 PROGRESS WAY
Practice Address - Street 2:STE 101 AND 102
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53579-1001
Practice Address - Country:US
Practice Address - Phone:815-821-3596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8216-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional